Evaluation of a continuing education intervention "Periodontics in General Practice"

Exploring the content and delivery of feedback facilitation co-interventions: a systematic review

BACKGROUND

Policymakers and researchers recommend supporting the capabilities of feedback recipients to increase the quality of care. There are different ways to support capabilities. We aimed to describe the content and delivery of feedback facilitation interventions delivered alongside audit and feedback within randomised controlled trials.

METHODS

We included papers describing feedback facilitation identified by the latest Cochrane review of audit and feedback. The piloted extraction proforma was based upon a framework to describe intervention content, with additional prompts relating to the identification of influences, selection of improvement actions and consideration of priorities and implications. We describe the content and delivery graphically, statistically and narratively.

RESULTS

We reviewed 146 papers describing 104 feedback facilitation interventions. Across included studies, feedback facilitation contained 26 different implementation strategies. There was a median of three implementation strategies per intervention and evidence that the number of strategies per intervention is increasing. Theory was used in 35 trials, although the precise role of theory was poorly described. Ten studies provided a logic model and six of these described their mechanisms of action. Both the exploration of influences and the selection of improvement actions were described in 46 of the feedback facilitation interventions; we describe who undertook this tailoring work. Exploring dose, there was large variation in duration (15-1800 min), frequency (1 to 42 times) and number of recipients per site (1 to 135). There were important gaps in reporting, but some evidence that reporting is improving over time.

CONCLUSIONS

Heterogeneity in the design of feedback facilitation needs to be considered when assessing the intervention's effectiveness. We describe explicit feedback facilitation choices for future intervention developers based upon choices made to date. We found the Expert Recommendations for Implementing Change to be valuable when describing intervention components, with the potential for some minor clarifications in terms and for greater specificity by intervention providers. Reporting demonstrated extensive gaps which hinder both replication and learning. Feedback facilitation providers are recommended to close reporting gaps that hinder replication. Future work should seek to address the 'opportunity' for improvement activity, defined as factors that lie outside the individual that make care or improvement behaviour possible.

REVIEW REGISTRATION

The study protocol was published at: https://www.protocols.io/private/4DA5DE33B68E11ED9EF70A58A9FEAC02 .

Clinical outcomes of performance of dental students using erythritol powder by means of air polishing with ultrasonic debridement with students' assessment: Part II

OBJECTIVE

Assessment of a dental student's clinical performance is essential for providing feedback for improving education. This study evaluated the ability of undergraduate dental students to treat periodontal patients with two techniques, ultrasonic debridement with polishing (UD+P) and the erythritol powder air polishing with ultrasonic instrumentation (EPAP+UD) in a split-mouth design.

METHODS

The study was conducted on undergraduate students with patients suffering from gingivitis and stage I periodontitis with grade A. The evaluation consisted of two parts: first, assessment of the student by clinical indices (full mouth plaque index (FMPI), calculus index (CI), remaining calculus index (RCI), modified gingival index (MGI) and papillary bleeding index (PBI)) at baseline, immediately and after 2 weeks. In addition to assessing treatment time for each student; and second, obtaining student feedback about the two methods used.

RESULTS

Five undergraduate fourth years' students, and thirteen patients participated. Statistically significant decreases in FMPI, CI, MGI and PBI between baseline and 2 weeks post-treatment were noted in both test and control groups. At 2 weeks of inter-group comparisons, there was a statistically significant difference in FMPI and MGI indices, and immediately after the treatment, there was also a significant reduction in FMPI and CI. Treatment time was significantly less for the EPAP+UD method, and it got 10-time method preferring in comparison with the control group (UD+P) by students.

CONCLUSION

The undergraduate dental student has the capacity to treat the periodontal patient using both approaches with a preference for the EPAP+UI approach over UI+P. In addition, this EPAP+UI is a promising method of education.

Meta-analyses involving cluster randomization trials: a review of published literature in health care

Throughout the 1980s and 1990s cluster randomization trials have been increasingly used to evaluate effectivenessof health care intervention. Such trials have raised several methodologic challenges in analysis. Meta-analyses involving cluster randomization trials are becoming common in the area of health care intervention. However, as yet there has been no empirical evidence of current practice in the meta-analyses. Thus a review was performed to identify and examine synthesis approaches of meta-analyses involving cluster randomization trials in the published literature. Electronic databases were searched for meta-analyses involving cluster randomization trials from the earliest date available to 2000. Once a meta-analysis was identified, papers on the relevant cluster randomization trials included were also requested. Each of the original papers of cluster randomization trials included was examined for its randomized design and unit, and adjustment for clustering effect in analysis. Each of the selected meta-analyses was then evaluated as to its synthesis concerning clustering effect. In total, 25 eligible meta-analyses were reviewed. Of these, 15 meta-analyses reported simple conventional methods of the fixed-effect model as method of analysis, while six did not incorporate the cluster randomization trial results in the synthesis methods but described the trial results individually. Three meta-analyses attempted to account for the clustering effect in the synthesis methods but approaches were in arbitrary. Fifteen meta-analyses included more than one cluster randomization trial, each of which included cluster randomization trials with a mixture of randomized designs and units, and units of analysis. These mixture situations might increase heterogeneity, but have not been considered in any meta-analysis. Some methods dealing with a binary outcome for some specific situations have been discussed. In conclusion, some difficulties in the quantitative synthesis procedures were found in the meta-analyses involving cluster randomization trials. Recommendations in the applications of approaches to some specific situations in a binary outcome variable have also been provided. There are still, however, several methodologic issues of the meta-analyses involving cluster randomization trials that need to be investigated further.

Successful clinical and organisational change in endodontic practice: a qualitative study

The aim of this study was to explicate and describe the qualitative meaning of successful clinical and organizational change in endodontic practice, following a comprehensive implementation program, including the integration of the nickel-titanium-rotary-technique. After an educational intervention in the Public Dental Service in a Swedish county, thematic in-depth interviews were conducted, with special reference to the participants' experience of the successful change. Interviews with four participants, were purposively selected on the basis of occupation (dentist, dental assistant, receptionist, clinical manager), for a phenomenological human scientific analysis. Four constituents were identified as necessary for the invariant, general structure of the phenomenon: 1) disclosed motivation, 2) allowance for individual learning processes, 3) continuous professional collaboration, and 4) a facilitating educator. The perceived requirements for achieving successful clinical and organizational change in endodontic practice were clinical relevance, an atmosphere which facilitated discussion and allowance for individual learning patterns. The qualities required in the educator were acknowledged competence with respect to scientific knowledge and clinical expertise, as well as familiarity with conditions at the dental clinics. The results indicate a complex interelationship among various aspects of the successful change process.

Audit and feedback had small but potentially important improvements in professional practice

DATA SOURCES

Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Medline, Ovid; Embase, CINAHL, EBSCO, Science Citation Index and Social Sciences Citation Index, ISIWeb of Science

STUDY SELECTION

Randomised trials of audit and feedback that reported objectively measured health professional practice or patient outcomes.

DATA EXTRACTION

Data were abstracted by two independent review authors using a data extraction form. The following factors were examined as possible explanations for the variation in the effectiveness of interventions across comparisons; format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient and risk of bias within the trial itself. Risk of bias was assessed using EPOC criteria. The degree of confidence in the estimate of effect across studies was assessed using the GRADE approach. All outcomes were expressed as compliance with desired practice and both professional and patient outcomes were assessed, though separately.

RESULTS

One hundred and forty studies were included. Using 70 of these 108 comparisons were made. After excluding studies at high risk of bias there were 82 comparisons from 49 studies with dichotomous outcomes, and the weighted median adjusted RD was 4.3% (interquartile range (IQR) 0.5% to 16%). For studies with continuous outcomes the weighted median adjusted percentage change relative to control was 1.3% (IQR = 1.3%to 28.9%). For patient outcomes the weighted median RD was 0.4% (IQR -1.3% to 1.6%) in studies reporting dichotomous outcomes, and the weighted median percentage change was 17% (IQR 1.5% to 17%) for studies with continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats and when it includes both explicit targets and an action plan.

CONCLUSIONS

Audit and feedback generally lead to small but potentially important improvements in professional practice.

Audit and feedback: effects on professional practice and healthcare outcomes

BACKGROUND

Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.

MAIN RESULTS

We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.

AUTHORS' CONCLUSIONS

Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

Educational outreach visits: effects on professional practice and health care outcomes

BACKGROUND

Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting.

OBJECTIVES

To assess the effects of EOVs on health professional practice or patient outcomes.

SEARCH STRATEGY

For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL.

SELECTION CRITERIA

Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention.

MAIN RESULTS

We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed.

AUTHORS' CONCLUSIONS

EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality.

MAIN RESULTS

Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.

AUTHORS' CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

The diffusion of innovation in dentistry: A review using rotary nickel-titanium technology as an example

Technological innovations are crucial for the advancement of the art and science of clinical dentistry. While some innovations suffer a lack of support, resulting in general nonacceptance, others are gradually adopted and supersede previous techniques and/or materials. Very little has been published in the dental literature concerning the reasons for the adoption, nonadoption, or rejection of new technology in dentistry. This paper reviews the diffusion of innovation in dentistry, with an emphasis on the adoption of rotary nickel-titanium endodontic instruments. Factors affecting adoption of new technology include a complex interplay of perceived benefits and advantages, and psychosocial and behavioral factors, in decision making. The importance of both dental school teaching and continuing education in dentistry is highlighted, emphasizing that such courses must be of a very high caliber.

Clinical trials in dental primary care: what research methods have been used to produce reliable evidence?

OBJECTIVE

To identify controlled clinical trials done exclusively in dental primary care and to classify the research according to design. Details of any procedures used to recruit general dental practitioners and any special organisational arrangements were also collected.

DESIGN

A scoping literature review.

SETTING

Dental primary care defined as general dental practice, community and school dental settings.

PARTICIPANTS

Published randomised controlled trials using randomised or quasi randomised approaches and controlled clinical trials were considered for inclusion in the review. Reports were excluded if they did not describe either a randomised controlled trial or a controlled trial. Studies were excluded if the setting was not primary dental care or the intervention was for non-dental conditions. Conference abstracts without a full report and trials published in a language other than English were also excluded.

MAIN OUTCOMES

Experimental and quasi-experimental designs, clinical areas and different kinds of strategies used to recruit dentists, any organisational arrangements made to support research in dental primary care.

RESULTS

The search of the Cochrane Oral Health Group Controlled Trials Register found 174 articles. Forty-three randomised controlled trials met the inclusion criteria. Trials to evaluate the effects of interventions for types of anaesthesia, periodontal diseases, smoking cessation techniques, dental materials, organisational aspects of dental care, patient anxiety, post extraction healing rates, antibiotics were identified. All were done in general dental practice. Trials in school and community settings were also included.

CONCLUSIONS

Practice-based research needs to be encouraged to provide dental primary care with relevant evidence upon which effective treatment can be based. This review shows there are few trials done in dental primary care to inform clinical practice, most of which have been reported since 1997. The range of trial designs shows that this method of evaluation can be used to evaluate dental primary care interventions and this is promising for those with an interest in improving dental patient outcomes. More research on how to recruit dentists into clinical trial research must be done.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers.

OBJECTIVES

To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that reported objectively measured professional practice or health care outcomes in which at least one group received an intervention designed (or tailored) to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken.

MAIN RESULTS

We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.

Effectiveness of interventions to promote continuing professional development for dentists

BACKGROUND

Continuing education is incumbent upon dentists as health professionals, but its promotion may be required, particularly in order to ensure regular professional updating. Continuing professional development may be delivered in a variety of ways, and new strategies and techniques must be evaluated for effectiveness.

AIM

To evaluate the effectiveness of two interventions utilizing the philosophies and techniques of the discipline of Quality Improvement.

METHOD

A self-assessment instrument (a manual) for quality dental practice was developed using the Delphi technique. A randomized, controlled trial of the interventions was conducted under field conditions for dental practice in Victoria, Australia. Dentists in Test Groups 1 and 2 completed the self-assessment manual, and received relevant references and their own scores for the manual in comparison with empirical standards. Dentists in Test Group 1 also attended a continuing education course on Quality Improvement. Dentists in Control Group 1 completed the manual only and received feedback of their scores. Dentists in Test Groups 1 and 2, and in Control Group 1 completed the manual again after 1 year as a post-intervention follow-up. Dentists in Control Group 2 completed the manual only at 1 year.

RESULTS

The intervention involving self-assessment, receipt of scores and references for the manual resulted in modest improvements in total scores for dentists after 1 year, although a response bias was apparent.

CONCLUSION

An effective method of facilitating change in quality dental practice was identified. Assessment of strategies and techniques for professional development of dentists should include observation of patterns of participation.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken.

MAIN RESULTS

We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice.

REVIEWER'S CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Changing doctor prescribing behaviour

The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals.